Medical Policies

Optima Health Plan has developed medical policies that serve as guidelines for coverage decisions and assist with administering plan benefits. The policies express Optima’s determination of whether certain services are medically necessary, and they are based upon a review of currently available clinical information. Medical policies are not a substitute for clinical judgment. These policies are not an explanation of benefits. Providers are reminded to always verify member benefits and prior authorization requirements for the requested service. Members may contact customer services representatives for specific coverage information. These medical policies do not supersede any regulatory requirements.

Medical policies can be highly technical and complex and are provided here for informational purposes. These medical policies are intended for use by health care professionals. The medical policies do not constitute medical advice or medical care. Treating health care professionals are solely responsible for diagnosis, treatment and medical advice. Optima Health members should discuss the information in the medical policies with their treating health care professionals.

Medical technology is constantly evolving, and these medical policies are subject to change without notice, although Optima Health will notify providers as required in advance of changes that could have a negative impact on benefits. Additional medical policies may be developed from time to time and some may be withdrawn from use. Medical policies that have become obsolete will be archived as appropriate.

Medicaid & Medicare Codes